+2 more
Patient admitted due to left leg finger swelling and pain Present complaint swelling and redness in left 4th finger Swelling from 4 months ago Consulted thuong nhat hospital and he didn't reduce the symptoms on 29/6/2026 he admitted to the truong vuong hospital The pain present all the time When he touches and walking on light pressure he feels pain sometimes he notices white color pus Pain does not radiate to any other joint Pain score 6/10 Gout attack history 3 yrs ago he got his 1st gout attack on the right leg 4th finger and cut it on 2023 This is 2nd attack since 3 yrs Previous attack was same as now While getting the last attack he also had pain in knee joint and the knee joint is still present He relieve pain when he takes rest He has specific diet he avoids non veg he did not eat any red meat and sea food He consumes alcohol 2 to 3 times a year He has no recent infection or last surgery He has no dehydration no trauma ,no excessive exercise He has no joint stiffness No lumps or nodules No urinary symptoms Past history Has past history of hypertension He took medication for 4 yrs and medication is unknown Family history No allergy No family history No weight loss Examination Musculoskeletal Morning stiffness no On observation mild swelling no redness On palpation crepitus seen in left leg Patella tap test negative not more fluid present Cardio normal Got normal. Skin No rashes no ulceration ,tenderness Systematic No fever,no fatiye no weight loss Functional impact Pain on walking Cannot able to climb stairs In right hand 3 rd MCP has gout and in 2nd finger he had trauma and got abnormality in younger age and also he had gout on the 2nd finger. From the given information above and the image make me a medical record in the format for given file
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The medical record is complete. Here it is for download:
Ngo Xuan Ky Medical Record
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Here is a summary of everything that was compiled into this record, following the exact same format as the template PDF:
INTERNAL MEDICINE CASE RECORD - Summary
Patient: Ngo Xuan Ky | Male | DOB: 10/10/1943 | Age: 83
Admitted: 29/06/2026, 16:55 | Trung Vuong Hospital, Room 11, Bed BCa
Treating Doctor: BS. Truong Anh Minh
Reason for Admission
Swelling, pain, and pus discharge from the left foot 4th toe - acute gout attack with suspected secondary infection / osteomyelitis.
Key Clinical Findings
- 4-month history of left 4th toe swelling and pain, VAS 6/10
- White pus discharge noted; pain worse on touch and walking, relieved by rest
- Second gout attack (first was right 4th toe, surgically removed 2023)
- Ongoing knee joint pain (gout-related); gout deposits in right hand 3rd MCP and 2nd finger
- Hypertension on medication x4 years; avoids red meat/seafood; minimal alcohol
Vitals: BP 130/70 | HR 82 | Temp 37°C | RR 20 | SpO2 96% | BMI 22.2 | GCS 15/15
Investigations (Key Abnormals)
| Test | Result | Reference | Flag |
|---|---|---|---|
| WBC | 12.62 K/µL | 4.4-10.8 | HIGH |
| NEU# | 8.70 K/µL | 2.0-6.9 | HIGH |
| MONO# | 1.43 K/µL | 0-0.9 | HIGH |
| IG# (immature granulocytes) | 0.34 K/µL | 0-0.06 | HIGH |
| Uric Acid | 519 µmol/L | 208-428 | HIGH |
| Creatinine | 111 µmol/L | 59-104 | HIGH |
| eGFR | 58 mL/min/1.73m² | >90 | LOW (CKD G3) |
| ECG | CRBBB + right axis deviation | - | Abnormal |
| Glucose, Electrolytes, LFTs | All normal | - | Normal |
Diagnoses
- Acute gout arthritis - left foot 4th toe (M10)
- Localised skin/subcutaneous infection (L08) with pus discharge
- Suspected osteomyelitis left foot (M86.8) - pending X-ray and biopsy
- Hypertension | CKD Stage 3 | CRBBB
Treatment
- Paracetamol 500 mg x2/day (pain relief)
- Low-purine diet, limb elevation, wound dressing
- Pending: antibiotics and urate-lowering therapy (colchicine/allopurinol - dose-adjusted for eGFR 58)
- Imaging: left foot X-ray + chest X-ray ordered
- Biopsy/culture from left foot tissue ordered
- NT-proBNP ordered; cardiology review for CRBBB
Give it in chat
INTERNAL MEDICINE CASE RECORD
(ENDOCRINOLOGY / GENERAL DEPARTMENT - TRUNG VUONG HOSPITAL)
I. ADMINISTRATIVE INFORMATION
| Full name | Ngo Xuan Ky |
| Sex | Male |
| Date of birth | 10/10/1943 |
| Age | 83 years old |
| Address | 356/16/1 Go Dau, Tan Son Nhi Ward, Ho Chi Minh City |
| Health insurance number | LH24849214940074908 (BHYT) |
| Date of admission | 29/06/2026 at 16:55 |
| Ward / Room / Bed | Khoa Noi Tiet - Tong Hop / Phong 11 / Giuong BCa |
| Admitting doctor | BS. Truong Anh Minh |
| Referral source | Previously attended Thuong Nhat Hospital; no symptom relief; referred to Trung Vuong Hospital |
II. MEDICAL RECORD
1. Reason for Admission
Swelling and pain of the left foot 4th toe with pus discharge - acute gout attack with suspected secondary infection / osteomyelitis.
2. History of Present Illness
Mr. Ngo Xuan Ky, an 83-year-old male, was admitted on 29/06/2026 via the emergency department of Trung Vuong Hospital. He presented with a 4-month history of progressive swelling and redness of the left foot 4th toe.
He initially sought treatment at Thuong Nhat Hospital but did not experience symptom relief. He was subsequently admitted to Trung Vuong Hospital on 29/06/2026 for further management.
Presenting symptoms:
- Constant pain in the left 4th toe, rated 6/10 on the numerical pain scale
- Pain worsens on touch and with light pressure (on walking)
- White-coloured pus occasionally noted at the affected site
- Pain relieved by rest
- No radiation to other joints
- No joint stiffness
- No lumps or nodules detected
Functional impact:
- Pain on walking
- Unable to climb stairs
This is his second gout attack in 3 years. His first attack occurred approximately 3 years ago, affecting the right foot 4th toe; that toe was surgically removed in 2023. The current presentation is similar to the previous attack.
During his last attack he also developed pain in the knee joint; knee pain is still present at this admission. The right hand 3rd MCP joint has a known gout deposit. The right hand 2nd finger sustained trauma in younger age and developed a deformity; gout also affects the right 2nd finger.
3. Dietary and Lifestyle History
- Follows a specific low-purine diet: avoids all non-vegetarian food; does not eat red meat or seafood
- Alcohol: 2 to 3 times per year (occasional, minimal)
- No recent infection; no recent surgery
- No dehydration, no trauma, no excessive exercise reported
4. Past Medical History
- Hypertension - on antihypertensive medication for 4 years (medication name unknown)
- First gout attack 3 years ago (right foot 4th toe); surgical amputation of that toe in 2023
- Right hand: 3rd MCP joint gout; 2nd finger - old traumatic deformity with superimposed gout
- No known drug allergies
- No recent surgery
5. Family History
- No family history of gout or rheumatological disease
- No family history of renal or cardiovascular disease documented
6. Systems Review
| System | Findings |
|---|---|
| General | No fever, no fatigue, no weight loss |
| Musculoskeletal | Pain and swelling left 4th toe; knee pain; see examination |
| Cardiovascular | Normal |
| Respiratory | Normal |
| Gastrointestinal | Normal |
| Urinary | No urinary symptoms |
| Skin | No rashes; no ulceration; tenderness over affected toe |
| Neurological | No focal deficits |
7. Physical Examination
Vital Signs on Admission (29/06/2026 at 16:55):
| Parameter | Value |
|---|---|
| Pulse | 82 beats/min |
| Temperature | 37°C |
| Blood Pressure | 130/70 mmHg |
| Respiratory Rate | 20 breaths/min |
| SpO2 | 96% |
| BMI | 22.2 kg/m² |
| Glasgow Coma Scale | 15/15 |
General Condition: Conscious, alert, cooperative. Stable. No acute distress.
Musculoskeletal:
- Morning stiffness: Absent
- Left foot 4th toe: Mild swelling on observation; no active redness at time of examination
- Palpation: Crepitus noted over left foot region
- Patella tap test: Negative - no significant knee effusion
- Right hand 3rd MCP joint: Gout deposit noted
- Right hand 2nd finger: Old traumatic deformity with superimposed gout changes
- No tophi; no subcutaneous nodules
Cardiovascular: Heart sounds normal; regular rate and rhythm; no chest pain; no palpitations
Respiratory: Normal breathing; no cough; no oxygen requirement
Skin: No rashes; no ulceration; tenderness and pus (white discharge) at left 4th toe
8. Case Summary
Mr. Ngo Xuan Ky, an 83-year-old male with known gout (first attack 3 years ago, right 4th toe surgically removed 2023) and hypertension, presented with a 4-month history of swelling, pain, and pus discharge from the left 4th toe. This is his second gout attack. He maintains a low-purine diet and drinks alcohol only rarely. Examination revealed mild swelling, crepitus, and pus at the left 4th toe without active redness.
Laboratory results confirmed markedly elevated serum uric acid (519 µmol/L; ref 208-428), raised WBC (12.62 K/µL) with neutrophilia and significantly elevated immature granulocytes (IG# 0.34; ref 0-0.06), consistent with acute inflammatory and infective process. eGFR was mildly reduced at 58 mL/min/1.73m² (CKD Stage 3). ECG showed complete right bundle branch block (CRBBB) with right axis deviation. Blood pressure mildly elevated at 130/70 mmHg.
Working diagnosis from the admitting team: Gout (M10) + localised skin/subcutaneous infection (L08) + suspected osteomyelitis left foot (M86.8).
9. Problem List
- Acute gout arthritis - left foot 4th toe (M10) - 2nd attack in 3 years
- Localised skin and subcutaneous infection, left foot (L08) - pus discharge
- Suspected osteomyelitis, left foot (M86.8) - pending imaging and biopsy confirmation
- Hyperuricaemia - serum uric acid 519 µmol/L (elevated)
- Leukocytosis with neutrophilia and elevated immature granulocytes - infective/inflammatory response
- Hypertension - on medication (name unknown)
- CKD Stage 3 - eGFR 58 mL/min/1.73m² (creatinine 111 µmol/L)
- Complete right bundle branch block (CRBBB) with right axis deviation - ECG finding
- Knee joint pain (bilateral) - likely gout-related, ongoing
- Right hand gout deposits - 3rd MCP and 2nd finger
- History of right 4th toe amputation for gout (2023)
10. Differential Diagnosis
| Diagnosis | Supporting Reasoning |
|---|---|
| Acute gout arthritis (most likely) | Known gout history; markedly elevated uric acid 519 µmol/L; typical presentation with swollen painful digit; prior attacks same pattern; polyarticular gout involvement confirmed |
| Septic arthritis / Osteomyelitis | Pus discharge; raised WBC 12.62 with neutrophilia; markedly elevated IG# (immature granulocytes); 4-month indolent course; crepitus; admitting team coded M86.8 (suspected osteomyelitis) and L08 (localised infection) |
| Infected tophus (tophaceous gout with secondary infection) | Chronic polyjoint gout with pus could represent an infected tophus; consistent with longstanding hyperuricaemia and multi-site involvement |
| Cellulitis | Localised inflammation; however pus and bone-involvement suggestion favour deeper infection superimposed on gout |
| Diabetic foot infection | Less likely - glucose 5.2 mmol/L is normal; no documented DM; cannot be fully excluded without HbA1c |
11. Investigations
Haematology (29/06/2026):
| Test | Result | Unit | Reference Range | Flag |
|---|---|---|---|---|
| WBC | 12.62 | K/µL | 4.4 - 10.8 | HIGH |
| NEU# | 8.70 | K/µL | 2.0 - 6.9 | HIGH |
| NEU% | 69.0 | % | 49.0 - 72.0 | Normal |
| LYM# | 1.86 | K/µL | 0.6 - 3.4 | Normal |
| LYM% | 14.7 | % | 20.0 - 42.2 | LOW |
| MONO# | 1.43 | K/µL | 0.0 - 0.9 | HIGH |
| MONO% | 11.3 | % | 0.0 - 12 | Normal |
| EOS# | 0.24 | K/µL | 0.0 - 0.7 | Normal |
| EOS% | 1.9 | % | 0.0 - 7 | Normal |
| BASO# | 0.05 | K/µL | 0.0 - 0.2 | Normal |
| BASO% | 0.4 | % | 0.0 - 2.5 | Normal |
| IG# | 0.34 | K/µL | 0.0 - 0.06 | HIGH |
| IG% | 2.7 | % | 0.0 - 0.6 | HIGH |
| RBC | 4.41 | M/µL | 4.3 - 5.8 | Normal |
| HGB | 13.7 | g/dL | 13 - 16.3 | Normal |
| HCT | 41.1 | % | 38 - 50 | Normal |
| MCV | 93.2 | fL | 80.0 - 97.0 | Normal |
| MCH | 31.1 | pg | 27.2 - 31.2 | Normal |
| MCHC | 33.3 | g/dL | 31.8 - 35.4 | Normal |
| RDW | 13.5 | % | 11.5 - 14.8 | Normal |
| PLT | 292 | K/µL | 150 - 450 | Normal |
| MPV | 8.5 | fL | 5 - 10 | Normal |
Biochemistry (29/06/2026):
| Test | Result | Unit | Reference Range | Flag |
|---|---|---|---|---|
| Blood Glucose | 5.2 | mmol/L | 3.9 - 5.6 | Normal |
| Serum Creatinine | 111 | µmol/L | 59 - 104 | HIGH |
| Serum Uric Acid | 519 | µmol/L | 208 - 428 | HIGH |
| eGFR | 58 | mL/min/1.73m² | > 90 | LOW - CKD G3 |
| Na+ | 141 | mmol/L | 135 - 145 | Normal |
| K+ | 3.7 | mmol/L | 3.5 - 5.1 | Normal |
| Cl- | 105 | mmol/L | 98 - 108 | Normal |
| AST (GOT) | 16 | U/L | < 50 | Normal |
| ALT (GPT) | 14 | U/L | < 50 | Normal |
ECG (29/06/2026 at 17:30):
| Parameter | Value |
|---|---|
| Heart Rate | 73 bpm |
| PR Interval | 178 ms |
| P Duration | 130 ms |
| QRS Duration | 135 ms |
| QT/QTc | 410 / 451 ms |
| P/QRS/T Axis | 27.8 / 94.0 / 5.9 degrees |
| R(V5)/S(V1) | 0.65 / 0.28 mV |
| R(V5)+S(V1) | 0.94 mV |
| Conclusion | Normal sinus rhythm. Severe right axis deviation. Complete right bundle branch block (CRBBB). Report requires physician confirmation. |
Further Investigations Ordered:
- Left foot X-ray
- Chest X-ray
- Skin and subcutaneous tissue biopsy - left foot (functional investigation form ordered 29/06/2026)
- NT-proBNP
- Total protein analysis
12. Definitive Diagnosis
Primary Diagnoses:
- Gout (M10) - Acute gout arthritis, left foot 4th toe; second attack in 3 years
- Localised infection of skin and subcutaneous tissue, left foot (L08) with pus discharge
- Suspected Osteomyelitis, left foot (M86.8) - pending imaging and biopsy confirmation
Comorbidities:
- Hypertension - on antihypertensive medication (4 years; name unknown)
- CKD Stage 3 - eGFR 58 mL/min/1.73m²
- Complete right bundle branch block (CRBBB) with right axis deviation
- History of right 4th toe amputation (2023) for gout
- Knee joint gout (ongoing bilateral knee pain)
- Tophaceous gout - right hand 3rd MCP and 2nd finger
13. Treatment Plan
A. Non-Pharmacological:
- Low-purine diet; continue avoidance of red meat and seafood; ensure adequate hydration
- Rest; elevate affected limb; reduce weight-bearing on left foot
- Regular wound dressing of left 4th toe
- Monitoring: blood pressure, pulse, temperature, respiratory rate and SpO2 every 12 hours
- Nursing care: Class III
- Patient education: gout diet, medication adherence, wound monitoring, signs of worsening infection
B. Pharmacological Treatment (from medical order sheet 29/06/2026):
| Drug | Dose | Route | Frequency | Notes |
|---|---|---|---|---|
| Paracetamol (Acetaminophen) | 500 mg | Oral | 2 times/day (19:00 and at night) | Analgesia |
| Urate-lowering therapy (allopurinol / febuxostat) | Dose-adjusted for eGFR 58 | Oral | Per physician order | Pending - avoid initiating during acute attack unless already established |
| Colchicine | Low dose, renal-adjusted | Oral | Per physician order | Pending - adjust for CKD G3 |
| Antibiotics | As per culture sensitivity | IV / Oral | Per physician order | Pending biopsy and culture result |
C. Monitoring Plan:
- Daily wound assessment of left 4th toe
- Blood pressure, heart rate, temperature, respiratory rate every 12 hours
- Repeat uric acid and inflammatory markers (WBC) after treatment initiation
- Follow-up X-ray of left foot to assess for osteomyelitis
- Renal function (creatinine, eGFR) - monitor closely given CKD G3; critical for medication dosing
- NT-proBNP result - cardiac function assessment
- ECG follow-up - CRBBB and right axis deviation require cardiology review
- Await biopsy result and cultures for definitive microbiological diagnosis
Treating Physician: BS. Truong Anh Minh
Hospital: Trung Vuong Hospital, Ho Chi Minh City
Department: Khoa Noi Tiet - Tong Hop (Endocrinology / General)
Admission Date: 29/06/2026
Record Date: 02/07/2026
In present illness put only problem what patient have not and now a past information and put those on past history and in case summary remove lab investigation values and info because lab comes after case summary right and also remove disease code and before differential diagnosis add preliminary diagnosis and it comorbidities
INTERNAL MEDICINE CASE RECORD
(ENDOCRINOLOGY / GENERAL DEPARTMENT - TRUNG VUONG HOSPITAL)
I. ADMINISTRATIVE INFORMATION
| Full name | Ngo Xuan Ky |
| Sex | Male |
| Date of birth | 10/10/1943 |
| Age | 83 years old |
| Address | 356/16/1 Go Dau, Tan Son Nhi Ward, Ho Chi Minh City |
| Health insurance number | LH24849214940074908 (BHYT) |
| Date of admission | 29/06/2026 at 16:55 |
| Ward / Room / Bed | Khoa Noi Tiet - Tong Hop / Phong 11 / Giuong BCa |
| Admitting doctor | BS. Truong Anh Minh |
| Referral source | Previously attended Thuong Nhat Hospital; no symptom relief; referred to Trung Vuong Hospital |
II. MEDICAL RECORD
1. Reason for Admission
Swelling and pain of the left foot 4th toe with pus discharge.
2. History of Present Illness
Mr. Ngo Xuan Ky, an 83-year-old male, presented with a 4-month history of progressive swelling and redness of the left foot 4th toe. He initially sought treatment at Thuong Nhat Hospital but did not experience symptom relief, and was admitted to Trung Vuong Hospital on 29/06/2026 for further management.
Current symptoms:
- Constant pain in the left 4th toe, rated 6/10 on the numerical pain scale
- Pain worsens on touch and with light pressure during walking
- White-coloured pus occasionally noted at the affected site
- Pain relieved by rest
- No radiation to other joints
- No joint stiffness
- No lumps or nodules detected
- Knee joint pain present (bilateral, ongoing)
Functional impact:
- Pain on walking
- Unable to climb stairs
3. Past Medical History
Gout History:
- First gout attack approximately 3 years ago affecting the right foot 4th toe; right 4th toe was surgically amputated in 2023
- Previous attack was similar in presentation to the current one
- During the last attack, knee joint pain also developed; knee pain has persisted since
- Right hand 3rd MCP joint: known gout deposit
- Right hand 2nd finger: old traumatic deformity from younger age with superimposed gout changes
Other Medical History:
- Hypertension - on antihypertensive medication for 4 years (medication name unknown)
- No known drug allergies
- No recent surgery
- No recent infection
- No dehydration, trauma, or excessive exercise
Dietary and Lifestyle History:
- Follows a low-purine diet: avoids all non-vegetarian food; does not eat red meat or seafood
- Alcohol: 2 to 3 times per year (occasional, minimal)
Family History:
- No family history of gout or rheumatological disease
- No family history of renal or cardiovascular disease documented
4. Systems Review
| System | Findings |
|---|---|
| General | No fever, no fatigue, no weight loss |
| Musculoskeletal | Pain and swelling left 4th toe; bilateral knee pain; see examination |
| Cardiovascular | Normal |
| Respiratory | Normal |
| Gastrointestinal | Normal |
| Urinary | No urinary symptoms |
| Skin | No rashes; no ulceration; tenderness and pus over affected toe |
| Neurological | No focal deficits |
5. Physical Examination
Vital Signs on Admission (29/06/2026 at 16:55):
| Parameter | Value |
|---|---|
| Pulse | 82 beats/min |
| Temperature | 37°C |
| Blood Pressure | 130/70 mmHg |
| Respiratory Rate | 20 breaths/min |
| SpO2 | 96% |
| BMI | 22.2 kg/m² |
| Glasgow Coma Scale | 15/15 |
General Condition: Conscious, alert, cooperative. Stable. No acute distress.
Musculoskeletal:
- Morning stiffness: Absent
- Left foot 4th toe: Mild swelling on observation; no active redness at time of examination
- Palpation: Crepitus noted over left foot region
- Patella tap test: Negative - no significant knee effusion
- Right hand 3rd MCP joint: Gout deposit noted
- Right hand 2nd finger: Old traumatic deformity with gout changes
- No tophi; no subcutaneous nodules
Cardiovascular: Heart sounds normal; regular rate and rhythm; no chest pain; no palpitations
Respiratory: Normal breathing; no cough; no oxygen requirement
Skin: No rashes; no ulceration; tenderness and white pus discharge at left 4th toe
6. Case Summary
Mr. Ngo Xuan Ky, an 83-year-old male with a background of gout and hypertension, presented with a 4-month history of progressive swelling, pain, and pus discharge from the left foot 4th toe. This is his second gout attack in 3 years. Despite maintaining a low-purine diet and drinking alcohol only rarely, he continues to have gout involvement across multiple joints including the knees and right hand. On examination, there was mild swelling of the left 4th toe with crepitus on palpation, white pus discharge, and a negative patella tap test. Blood pressure was mildly elevated at 130/70 mmHg. He is functionally limited - unable to climb stairs and has pain on walking.
7. Problem List
- Left foot 4th toe - swelling, pain, and pus discharge for 4 months
- Acute gout attack - second episode in 3 years
- Bilateral knee pain - ongoing since last gout attack
- Hyperuricaemia (elevated serum uric acid)
- Hypertension - on medication (name unknown)
- History of right 4th toe amputation (2023) for gout
- Tophaceous gout - right hand 3rd MCP and 2nd finger
- Functional limitation - pain on walking; unable to climb stairs
8. Investigations
Haematology (29/06/2026):
| Test | Result | Unit | Reference Range | Flag |
|---|---|---|---|---|
| WBC | 12.62 | K/µL | 4.4 - 10.8 | HIGH |
| NEU# | 8.70 | K/µL | 2.0 - 6.9 | HIGH |
| NEU% | 69.0 | % | 49.0 - 72.0 | Normal |
| LYM# | 1.86 | K/µL | 0.6 - 3.4 | Normal |
| LYM% | 14.7 | % | 20.0 - 42.2 | LOW |
| MONO# | 1.43 | K/µL | 0.0 - 0.9 | HIGH |
| MONO% | 11.3 | % | 0.0 - 12 | Normal |
| EOS# | 0.24 | K/µL | 0.0 - 0.7 | Normal |
| EOS% | 1.9 | % | 0.0 - 7 | Normal |
| BASO# | 0.05 | K/µL | 0.0 - 0.2 | Normal |
| BASO% | 0.4 | % | 0.0 - 2.5 | Normal |
| IG# | 0.34 | K/µL | 0.0 - 0.06 | HIGH |
| IG% | 2.7 | % | 0.0 - 0.6 | HIGH |
| RBC | 4.41 | M/µL | 4.3 - 5.8 | Normal |
| HGB | 13.7 | g/dL | 13 - 16.3 | Normal |
| HCT | 41.1 | % | 38 - 50 | Normal |
| MCV | 93.2 | fL | 80.0 - 97.0 | Normal |
| MCH | 31.1 | pg | 27.2 - 31.2 | Normal |
| MCHC | 33.3 | g/dL | 31.8 - 35.4 | Normal |
| RDW | 13.5 | % | 11.5 - 14.8 | Normal |
| PLT | 292 | K/µL | 150 - 450 | Normal |
| MPV | 8.5 | fL | 5 - 10 | Normal |
Biochemistry (29/06/2026):
| Test | Result | Unit | Reference Range | Flag |
|---|---|---|---|---|
| Blood Glucose | 5.2 | mmol/L | 3.9 - 5.6 | Normal |
| Serum Creatinine | 111 | µmol/L | 59 - 104 | HIGH |
| Serum Uric Acid | 519 | µmol/L | 208 - 428 | HIGH |
| eGFR | 58 | mL/min/1.73m² | > 90 | LOW - CKD G3 |
| Na+ | 141 | mmol/L | 135 - 145 | Normal |
| K+ | 3.7 | mmol/L | 3.5 - 5.1 | Normal |
| Cl- | 105 | mmol/L | 98 - 108 | Normal |
| AST (GOT) | 16 | U/L | < 50 | Normal |
| ALT (GPT) | 14 | U/L | < 50 | Normal |
ECG (29/06/2026 at 17:30):
| Parameter | Value |
|---|---|
| Heart Rate | 73 bpm |
| PR Interval | 178 ms |
| P Duration | 130 ms |
| QRS Duration | 135 ms |
| QT/QTc | 410 / 451 ms |
| P/QRS/T Axis | 27.8 / 94.0 / 5.9 degrees |
| R(V5)/S(V1) | 0.65 / 0.28 mV |
| R(V5)+S(V1) | 0.94 mV |
| Conclusion | Normal sinus rhythm. Severe right axis deviation. Complete right bundle branch block (CRBBB). Report requires physician confirmation. |
Further Investigations Ordered:
- Left foot X-ray
- Chest X-ray
- Skin and subcutaneous tissue biopsy - left foot
- NT-proBNP
- Total protein analysis
9. Preliminary Diagnosis
Primary Diagnosis:
- Acute gout arthritis - left foot 4th toe (second attack in 3 years)
- Localised skin and subcutaneous infection, left foot - with pus discharge
- Suspected osteomyelitis, left foot - pending imaging and biopsy confirmation
Comorbidities:
- Hypertension - on antihypertensive medication (4 years; name unknown)
- CKD Stage 3 - eGFR 58 mL/min/1.73m² (creatinine 111 µmol/L)
- Complete right bundle branch block (CRBBB) with right axis deviation - ECG finding
- History of right 4th toe amputation (2023) for gout
- Bilateral knee joint gout (ongoing)
- Tophaceous gout - right hand 3rd MCP and 2nd finger
10. Differential Diagnosis
| Diagnosis | Supporting Reasoning |
|---|---|
| Acute gout arthritis (most likely) | Known gout history; markedly elevated serum uric acid; typical presentation with swollen painful digit; prior attacks same pattern; polyarticular gout confirmed at multiple sites |
| Septic arthritis / Osteomyelitis | Pus discharge; raised WBC with neutrophilia and elevated immature granulocytes; 4-month indolent course; crepitus on palpation; bone involvement cannot be excluded until imaging and biopsy results available |
| Infected tophus (tophaceous gout with secondary infection) | Chronic polyjoint gout with pus could represent an infected tophus; consistent with longstanding hyperuricaemia and multi-site involvement |
| Cellulitis | Localised inflammation present; however pus and possible bone involvement favour deeper infection superimposed on gout |
| Diabetic foot infection | Less likely - blood glucose is normal; no documented diabetes; cannot be fully excluded without HbA1c |
11. Definitive Diagnosis
Primary Diagnoses:
- Acute gout arthritis - left foot 4th toe; second attack in 3 years
- Localised infection of skin and subcutaneous tissue, left foot with pus discharge
- Suspected osteomyelitis, left foot - pending imaging and biopsy confirmation
Comorbidities:
- Hypertension - on antihypertensive medication (4 years; name unknown)
- CKD Stage 3 - eGFR 58 mL/min/1.73m²
- Complete right bundle branch block (CRBBB) with right axis deviation
- History of right 4th toe amputation (2023) for gout
- Bilateral knee joint gout (ongoing)
- Tophaceous gout - right hand 3rd MCP and 2nd finger
12. Treatment Plan
A. Non-Pharmacological:
- Low-purine diet; continue avoidance of red meat and seafood; ensure adequate hydration
- Rest; elevate affected limb; reduce weight-bearing on left foot
- Regular wound dressing of left 4th toe
- Monitoring: blood pressure, pulse, temperature, respiratory rate and SpO2 every 12 hours
- Nursing care: Class III
- Patient education: gout diet, medication adherence, wound monitoring, signs of worsening infection
B. Pharmacological Treatment:
| Drug | Dose | Route | Frequency | Notes |
|---|---|---|---|---|
| Paracetamol (Acetaminophen) | 500 mg | Oral | 2 times/day (afternoon and night) | Analgesia |
| Urate-lowering therapy (allopurinol / febuxostat) | Dose-adjusted for eGFR 58 | Oral | Per physician order | Avoid initiating during acute flare unless already established |
| Colchicine | Low dose, renal-adjusted | Oral | Per physician order | Adjust for CKD Stage 3 |
| Antibiotics | Per culture sensitivity | IV / Oral | Per physician order | Pending biopsy and culture result |
C. Monitoring Plan:
- Daily wound assessment - left 4th toe
- Blood pressure, heart rate, temperature, respiratory rate every 12 hours
- Repeat uric acid and WBC after treatment initiation
- Follow-up X-ray left foot to assess for osteomyelitis progression
- Renal function (creatinine, eGFR) monitoring - important for medication dose adjustment
- NT-proBNP result review - cardiac function assessment
- Cardiology review for CRBBB and right axis deviation
- Await biopsy and culture results for definitive microbiological diagnosis
Treating Physician: BS. Truong Anh Minh
Hospital: Trung Vuong Hospital, Ho Chi Minh City
Department: Khoa Noi Tiet - Tong Hop (Endocrinology / General)
Admission Date: 29/06/2026
Record Date: 02/07/2026
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